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SAN JOAQUIN COUNTY <br /> FILE C3 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> UNIT IV <br /> WELL PERMIT APPLICATION <br /> ?AV <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Jo0uin County Environmental Health Department. <br /> Assessor's <br /> Well Location Cross Street ity Za <br /> Property Zip Parcel <br /> Owner A lop&1ktZ Ad UL Address Box city 6W4— zip t?5�76 7 Phone# <br /> ./Ox pe.,tr q6go 6a,4pt q,3,6 city Z," <br /> C-67 Contractor WD(, Address _a on p Lic# Phone <br /> Consultant/SubCntr 516L.,L e-c- Address 10 %000ty P"61411-, Lic# <br /> Phone qg- jf/,Z <br /> GIs Coordinates:X 'y Township Range <br /> Section <br /> WORK TO BE PERFORMED: <br /> [D NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH.HAND-AUGER,OTHER-) 0 DESTRUCTION(CHOOSE TYPE BELOW) <br /> El SOIL BORING# 0 OVER-BORE DIAMETER <br /> [I WELL# [j PRESSURE GROUT <br /> ®-*OTHER 1116 Ww.-Rt-tc,,or &,-. VVLFJU-dq GROUT SPECIFICATIONS <br /> EXPLOSIVES DETONATING CARD <br /> COMMENTS:. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Ir <br /> .MONITORING El HOLLOW STEM DIA.OF BOREHOLE f) 0 MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA: <br /> El EXTRACTION El AIR HAMMER/DRIVEN CASING THICKNESS :Z9 '10 TYPE OF CASING:0 STEEL)5 PVC [I OTHER <br /> 0 VAPOR El MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> [I AIR SPARGEIOZONE [-I PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER_GROUT SPECIFICATIONS <br /> ❑OTHER: 0 OTHER: APPROX.BORING DEPTH BOLTED TRAFFIC BOX OR OSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED (it YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all a pl S. <br /> SignedCJ Title/Company <br /> h/ <br /> Print Name 1/ <br /> Date IF/ce 1/900 <br /> DEPARTMENT USE ONLY <br /> ®i'eaa <br /> SITE MAP IN UNIT IV FILE.ADDRESS: dx;�- <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: - AID# FAC# <br /> PE CODES F AMT REMITTED=CHEOK,1 RECV-D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57 WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENT DOC <br /> EHD 29.01 10/28/09 L PERMIT APP <br />